Nursing care plans NANDA Nursing Diagnosis: Disturbed Sensory perception

NANDA Nursing Diagnosis Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Defining Characteristics: Poor concentration, auditory distortions, change in usual response to stimuli, restlessness, reported or measured change in sensory acuity, irritability, disoriented in time, in place, or with people; change in problem-solving abilities; change in behavior pattern; altered communication patterns; hallucinations; visual distortions

NOC Outcomes

• Body Image
• Cognitive Orientation
• Sensory Function: Vision
• Vision Compensation Behavior
• Cognitive Orientation
• Communication: Receptive Ability
• Distorted Thought Control
• Hearing Compensation Behavio

Client Outcomes

• Demonstrates understanding by a verbal, written, or signed response
• Demonstrates relaxed body movements and facial expressions
• Explains plan to modify lifestyle to accommodate visual or hearing impairment
• Remains free of physical harm resulting from decreased balance or a loss of vision, hearing, or tactile sensation
• Maintains contact with appropriate community resources

NIC Interventions

• Communication Enhancement: Hearing Deficit
• Cognitive Stimulation
• Environmental Management

Nursing Interventions and Rationales

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Nursing care plans for Dermatophytosis (tinea)

Nursing care plans for Dermatophytosis

Dermatophytosis (tinea) is a group of superficial fungal infections usually classified according to their anatomic location. Dermatophytosis may affect the scalp (tinea capitis), the bearded skin of the face (tinea barbae), the body (tinea corporis, occurring mainly in children), the groin (tinea cruris, or jock itch), the nails (tinea unguium, also called onychomycosis), and the feet (tinea pedis, or athlete's foot). These disorders vary from mild inflammations to acute vesicular reactions.

Tinea infections are prevalent in the United States and are usually more common in males than in females. Although remissions and exacerbations are common, with effective treatment, the cure rate is very high. About 20% of infected people develop chronic conditions.

Causes

Tinea infections result from dermatophytes (fungi) of the genera Trichophyton, Microsporum, and Epidermophyton. Transmission can occur directly through contact with infected lesions or indirectly through contact with contaminated articles, such as shoes, towels, or shower stalls. Some cases come from contact with contaminated animals or soil. Warm weather, humidity, and tight clothing encourage fungus growth

Complications

Hair or nail loss and secondary bacterial or candidal infections, resulting in inflammation, itching, tenderness, and maceration, are common complications of tinea infections.

Assessment Nursing care plans for Dermatophytosis

Tinea lesions vary in appearance and duration. Inspection of the patient with tinea capitis may expose small, spreading papules on the scalp that may progress to inflamed, pus-filled lesions (kerions). Patchy hair loss with scaling may be visible. Tinea barbae appears as pustular folliculitis in the bearded area.

In patients with tinea corporis, inspection and palpation reveal flat skin lesions at any site except the scalp, bearded skin, or feet. These lesions may be dry and scaly or moist and crusty; as they enlarge, their centers heal, producing the classic ring-shaped appearance. In patients with tinea cruris, inspection and palpation find raised, sharply defined, itchy red lesions in the groin that may extend to the buttocks, inner thighs, and external genitalia. Tinea unguium starts at the tip of one or more toenails (fingernail infection is less common). Inspection reveals gradual thickening, discoloration, and crumbling of the nail, with accumulation of subungual debris. Eventually, the nail may be completely destroyed.

Diagnoses Nursing care plans for Dermatophytosis (tinea)

• Acute pain
• Deficient knowledge (skin care regimen)
• Disturbed body image
• Impaired skin integrity
• Risk for infection

Key outcomes Diagnoses Nursing care plans for Dermatophytosis (tinea)

1. patient will report feelings of increased comfort.
2. patient and his family will demonstrate the appropriate skin care regimen.
3. patient will voice feelings about his changed body image.
4. patient will exhibit improved or healed wounds or lesions.
5. patient will avoid or minimize the risk of secondary infection.

Nursing interventions Patient teaching Base On NANDA nursing Diagnosis here

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Nursing care plans for Disturbed Body Image

Nursing Diagnosis : Disturbed Body Image
Nursing care plans for Disturbed Body Image
NANDA Definition: Confusion in mental picture of one's physical self

Defining Characteristics: Nonverbal response to actual or perceived change in structure and or function, verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function, erbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function, behaviors of avoidance, monitoring, or acknowledgment of one's body

Objective
Missing body part; actual change in structure or function; avoidance of looking at or touching body part,  intentional or unintentional hiding or overexposure of body part; trauma to nonfunctioning part; change in social involvement, change in ability to estimate spatial relationship of body to environment

Subjective
Change in lifestyle, fear of rejection or reaction by others,  focus on past strength, function, or appearance, negative feelings about body,  feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Body Image
• Child Development: 2 Years
• Child Development: 3 Years
• Child Development: 4 Years
• Child Development: 5 Years
• Child Development: Middle Childhood (6-11 Years)
• Child Development: Adolescence (12-17 Years)
• Distorted Thought Control
• Grief Resolution
• Psychosocial Adjustment: Life Change
• Self-Esteem

Client Outcomes
• States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
• Calls body part or loss by appropriate name
• Looks at and touches changed or missing body part
• Cares for changed or nonfunctioning part without inflicting trauma
• Returns to previous social involvement
• Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Nursing Interventions and Rationales

• Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image The five BII subscales-General Appearance, Body Competence, Others' Reaction to Appearance, Value of Appearance, and Body Parts-exhibited moderate to high internal reliability and concurrent validity.
• Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis. Clients are in shock during acute phase, and their own value system must be considered. Clients deal better with change over time.
• Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle. Changes in body image cause anxiety. People in this situation use a variety of unconscious coping mechanisms to deal with their altered body image (ABI). Defense mechanisms are normal, unless they are used so much that they interfere with rather than improve self-esteem.
• Identify clients at risk for body image disturbance (e.g., body builders, cancer survivors). The results of one study suggest that male body builders are at risk for body image disturbance and the associated psychological characteristics that have been commonly reported among eating disorder patients. These psychological characteristics also appear to predict steroid use in this group of males. Steroid users reported an elevated drive to put on muscle mass in the form of bulk.
• Clients should not be rushed into sharing their feelings. Feelings associated with complicated and emotionally powerful issues involving an altered body image take time to work through and express.
• Do not ask clients to explore feelings unless they have indicated a need to do so. Patients reported keeping their feelings to themselves as a frequently used coping strategy.
• Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs. Emphasizing strengths promotes a positive self-image. Planning for an event such as hair loss helps to decrease the anxiety associated with a sudden change in appearance.
• Encourage client to purchase clothes that are attractive and that de-emphasize their disability. Individuals with osteoporosis are not usually disabled but may perceive themselves as unattractive and experience social isolation as a result of ill-fitting clothes that accentuate the physical changes.
• Allow client and others gradual exposure to the body change. Begin by having the client touch the affected area; then use a mirror to look at it. Go to a hospital shop with a nurse or support person and discuss feelings associated with the reaction of others to the body change. Part of the rehabilitation process is graded exposure-the client moves from a protected to an unprotected environment with the support of the nurse. 
• Encourage client to discuss interpersonal and social conflicts that may arise. A good perception of body image is best achieved within a supportive social framework. Clients with an active social support network are likely to make better progress. Changes in physical appearance and function associated with disease processes need to be integrated into the interaction that occurs between patients and lay caregivers.
• Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths. It is important for clients to be involved in their own care. If they have received information about their altered body image, treatment, and rehabilitation, they will be able to make their own choices. Consequently they will be more likely to come to terms with and adapt to their ABI. Healthy adaptation to body image exists when the person is able to maximize ability despite disability .
• Help client accept help from others; provide a list of appropriate community resources (e.g., Reach to Recovery, Ostomy Association). Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning. 
• Help client describe self-ideal, identify self-criticisms, and be accepting of self. The perception of self-image involves knowing the self and what is important and valued. Disability causes individuals to live as changed human beings whether they are willing to or not.
• Encourage client to write a narrative description of their changes. An analysis based on the grounded theory method revealed that one's experience of coping or adjustment to a disability is represented as narratives about himself or herself. Each person with TBI reconstructed certain self-narratives when coping with their changed self-images and daily lives.
• Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure. Nurses must be aware of their nonverbal behavior; clients often become acutely aware of nurses' feelings as a result of the nurses' facial expressions, tone of voice, touch, or other behaviors.
• Encourage client to continue same personal care routine that was followed before the change in body image. It is preferable that this care be completed in the bathroom and not in bed. This routine gives the client privacy and also prevents the client from settling into an "invalid" role. Research has shown that women who resume familiar routines and habits heal better and suffer less depression than those who settle into the role of patient.

Geriatric

• Focus on remaining abilities. Have client make a list of strengths. Results from unstructured interviews with women aged 61 to 92 regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the "naturalness" of the aging process. Motivation and self-worth are increased in the elderly by highlighting their capabilities. Even a severely disabled client is usually capable of accomplishing some tasks. Normal changes in body image occur as a result of the aging process.
  

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the client's body image. The client's body image may be based on cultural perceptions, as well as influences from the larger social context.
• Validate the client's feelings with regard to the impact of health status on disturbances in body image. Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship.
• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. Body image disturbances are pervasive across western cultures and appear to increase in other cultures with acculturation to western ideals.

Home Care Interventions

• Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
• Assess family/caregiver level of acceptance of client's body changes.
• Be accepting of changes in all interactions with client and family and caregivers. Acceptance promotes trust.
• Help client to see new or changing roles in family. Point out ways in which the community can help support client and family strengths.
• Refer to medical social services for level of acceptance and possible financial impact of changes. Clients and caregivers may see the nurse's visit as being solely involved with physiological issues such as dressing, especially under managed care systems. Social worker visits can support the client or caregivers with dedicated time and can help the nurse be supportive and adapt interventions to promote acceptance. The nurse or social worker can introduce or reinforce use of community resources.
• Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part. The quicker the involvement in self-care, the greater the chances for permanent acceptance and positive self-esteem.
• Teach family and client complications of medical condition and when to contact physician.
• Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities. The quicker the reinvolvement in daily living activities and self-care, the greater the chances for permanent acceptance and positive self-esteem.
• If appropriate, provide home health aide support to help the client and family through ADL transition.
• Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures, assist with transfer/ambulation safety, or obtain use of a prosthetic device in the home setting.
• Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations (e.g., client with ostomy). Good nutrition and sleep patterns promote faster healing and better coping.
• Assist family with obtaining needed supplies. Cost of ostomy supplies and adaptive equipment can be an added stressor for the client. Community resources can assist.

Client/Family Teaching

• Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). Patient teaching by ET nurses may alleviate problems associated with altered body image in relation to the presence of an ostomy.
• Inform client of available community support groups; offer to make initial phone call. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning.
• Refer client to counseling for help adjusting to body change. Counseling is important for a client who is trying to create a new body ideal or work through a grief process.
• Provide printed material and didactic information for significant others. Some significant others prefer to receive didactic material rather than vent their feelings as a way of showing support.
• Encourage significant others to offer support. Social support from significant others enhances both emotional and physical health.
• Direct social support as follows: instruct regarding practical care, encourage appraisal support, encourage self-esteem support, and encourage sense of belonging. The preceding are four categories of support recognized in the body-image care model. Clients with an active social support network are likely to make better progress than those without support.
• Refer to an interdisciplinary team clients with ostomies who are having difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications Many clinical studies have found patients with ostomies to be a group facing multiple adjustment demands. One of these demands is coping with a significant change in body image. At the Medical College of Wisconsin, a team approach has been initiated; the ET nurse, the psychologist, and the surgeon deal with body image concerns together. The multidisciplinary approach has been demonstrated to be successful in facilitating adaptation to an altered body image.

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Nursing Care Plans for Diarrhea

Nursing Diagnosis: Diarrhea
Nursing care plans for Diarrhea
NANDA Definition: Passage of loose, unformed stools

Defining Characteristics:  Hyperactive bowel sounds, at least three loose liquid stools per day, urgency, abdominal pain, cramping

Related Factors:
Psychological
High stress levels and anxiety
Situational
Alcohol abuse,  toxins,  laxative abuse, radiation, tube feedings , adverse effects of medications, contaminants, travel
Physiological
Inflammation, malabsorption, infectious processes, irritation, parasites

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Bowel Elimination
• Electrolyte and Acid-Base Balance
• Fluid Balance
• Hydration
• Treatment Behavior: Illness or Injury

Client Outcomes
• Defecates formed, soft stool every day to every third day
• Maintains a rectal area free of irritation
• States relief from cramping and less or no diarrhea
• Explains cause of diarrhea and rationale for treatment
• Maintains good skin turgor and weight at usual level
• Contains stool appropriately (if previously incontinent)

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Diarrhea Management

Nursing Interventions and Rationales Nursing Care Plans for Diarrhea

• Assess pattern of defecation or have client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. Assessment of defecation pattern will help direct treatment.
• Identify cause of diarrhea if possible (e.g., viral, rotavirus, human immunodeficiency virus/HIV), food, medication effect, radiation therapy, protein malnutrition, laxative abuse, stress). Identification of the underlying cause is imperative because the treatment and expected outcome depend on it. If the onset of diarrhea is sudden with no obvious cause, a colonoscopy is recommended to rule out colon cancer. When reviewing medication, assess for medications that increase peristalsis, such as metoclopramide. HIV infection is also commonly associated with diarrhea.
• If client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, consider possibility of Clostridium difficile infection. difficile infection and pseudomembranous colitis have become increasingly common because of the frequent use of broad-spectrum antibiotics.
• Use Standard Precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing. Clostridium  difficile has been shown to be contagious and at times epidemic. One study of medical patients demonstrated that more than 30% developed nosocomial diarrhea after admission to a nursing unit, and the majority of cases were caused by Clostridium  difficile. Clostridium   difficile is spread by direct or indirect contact, placing other clients at risk for infection.
• Obtain stool specimens as ordered to either rule out or diagnose an infectious process (e.g., ova and parasites, Clostridium   difficile infection, bacterial cultures).
•  If client has infectious diarrhea, avoid using medications that slow peristalsis. If an infectious process is occurring, such as Clostridium   difficile infection or food poisoning, medication to slow down peristalsis should generally not be given. The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon.
• Observe and record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output. Documentation of output provides a baseline and helps direct replacement fluid therapy.
• Inspect, palpate, percuss, and auscultate abdomen; note whether bowel sounds are frequent.
• Assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness  and cause death in the very young, the chronically ill, and the elderly.
• Observe for symptoms of sodium and potassium loss (e.g., weakness, abdominal or leg cramping, dysrhythmia). Note results of electrolyte laboratory studies. Stool contains electrolytes; excessive diarrhea causes electrolyte abnormalities that can be especially harmful to clients with existing medical conditions.
• Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure specific gravity of urine if possible. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume.
• Weigh client daily and note decreased weight. An accurate daily weight is an important indicator of fluid balance in the body.
• Give clear fluids as tolerated, serving at lukewarm temperature.
• For children with diarrhea, give oral rehydration therapy liquids (Pedialyte) as directed by physician. Oral rehydration therapy is effective for treating mild to moderate dehydration in children with diarrhea and may help prevent the need for hospitalization with administration of IVs.
• If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea. The loss of proteins, electroytes, and water from diarrhea in a cancer client can lead to rapid deterioration and possibly fatal dehydration.
• If diarrhea is chronic and there is evidence of malnutrition, consult with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. A hydrolyzed formula contains protein that is partially broken down to small peptides or amino acids for people who cannot digest nutrients.
• Encourage client to eat small, frequent meals and to consume foods that normally cause constipation and are easy to digest . Encourage client to avoid milk products, foods high in fiber, and caffeine. Bland, starchy foods are initially recommended when starting to eat solid food again.
• Provide a readily available bedpan, commode, or bathroom.
• Maintain perirectal skin integrity. Cleanse with a mild cleansing agent (perineal skin cleanser). Apply protective ointment prn. If skin is still excoriated and desquamated, apply a wound hydrogel. Avoid the use of rectal Foley catheters. Moisture-barrier ointments protect the skin from excoriation. Rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture, and the nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care.
• If client is receiving a tube feeding, do not assume it is the cause of diarrhea. Perform a complete assessment to rule out other causes such as medication effects, sorbitol in medications, or an infection. Research has shown that tube feedings do not usually cause diarrhea. Howeve, sorbitol in medication has been linked to diarrhea.
• If client is receiving a tube feeding , suggest formulas that contain a bulking agent such as Jevity. Note rate of infusion, and prevent contamination of feeding by rinsing container every 8 hours and replacing it every 24 hours. Rapid administration of tube feeding and contaminated feedings have been associated with diarrhea. Bulking agents are useful in tube feedings to prevent diarrhea.

Geriatric

• Evaluate medications client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, ACE inhibitors, Hx-receptor antagonists, NSAIDS, anticholinergic agents, oral hypoglycemia agents, antibiotics, and others. A drug-associated cause should always be considered when treating diarrhea in the older person; many drugs can result in diarrhea.
• Monitor client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered. Impactions are more common in the elderly than in younger clients. It is very important that the client be checked for impaction before being given any antidiarrheal medication.
• Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if client has symptoms of dehydration or electrolyte disturbances such as lassitude, weakness, or prostration. Elderly clients can dehydrate rapidly. The greatest concern for elderly clients with severe diarrhea is hypokalemia. Hypokalemia is treatable but when missed can be fatal.
• Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea. Diarrhea can be a great source of embarrassment to the elderly and can lead to social isolation and a feeling of powerlessness.

Home Care Interventions Nursing Care Plans for Diarrhea

• Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.
• Assess for methods of handling soiled laundry if client is bedbound or has been incontinent. Instruct or reinforce Standard Precautions with family and bloodborne pathogen precautions with agency caregivers. The Bloodborne Pathogen Regulations of the Occupational Safety and Health Administration (OSHA) identify legal guidelines for caregivers.
• When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-the-counter medications when self-treating. Mixing over-the-counter medications can further irritate the gastrointestinal system, intensifying the diarrhea or causing nausea and vomiting.

Client and Family Teaching Nursing Care Plans for Diarrhea

• Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.
• Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.
• Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food).
• Help client to determine stressors and set up an appropriate stress reduction Care plans .
• Teach signs and symptoms of dehydration and electrolyte imbalance.

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